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<h1 class="p_Heading1"><span class="f_Heading1">HIV Exposed Infant Follow up Card</span></h1>

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<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A1_ICON" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><span style="font-weight: bold;"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A1','TOGGLE0186A1_ICON')">Introduction</a></span></td></tr></table></div><div id="TOGGLE0186A1" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><p>The HIV Exposed Infant (HEI) card has four (4) parts: </p>
<p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">1.</span>The front page (which summarizes patients details, key events before and after enrollment); </p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">2.</span>Replicated details from the child health cards (where similar details as on the mother/child‘s booklet are recorded); </p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">3.</span>Routine care and assessment (covering growth monitoring, prophylaxis and treatment)</p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">4.</span>Assessments for child development and TB infection.</p></td>
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<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A2_ICON" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><span style="font-weight: bold;"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A2','TOGGLE0186A2_ICON')">Purpose</a></span></td></tr></table></div><div id="TOGGLE0186A2" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><p>To serve as a detailed record of care for HIV exposed infants and facilitate follow up of the child until discontinuation – arising from testing HIV positive, confirmed negative, death, or dropping out for any reason than the foregoing. </p>
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<p style="text-indent: -18px; margin: 0px 0px 0px 28px;">&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A3_ICON" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><span style="font-weight: bold;"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A3','TOGGLE0186A3_ICON')">Fill in a New HEI follow up card</a></span></td></tr></table></div><div id="TOGGLE0186A3" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><p>The active technical area should be ANC antenatal and postnatal clinic</p>
<p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">1.</span>From the Patient Home Page, click on the Create New Form link and select the HEI follow up card </p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">2.</span>Fill in the form, making sure you fill in the required fields. Note that some of the fields will be auto populated.</p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">3.</span>Click Save</p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">4.</span>IQCare displays a message alerting you of any required fields not filled</p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">5.</span>IQCare displays a message alerting you of a successful save and asks you if you wish to exit or stay on the form (for continued field data entry.) </p></td>
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<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A4_ICON" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><span style="font-weight: bold;"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A4','TOGGLE0186A4_ICON')">Update HEI follow up Card</a></span></td></tr></table></div><div id="TOGGLE0186A4" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">1.</span>To access a previously filled HEI form click on View Existing Forms and find the HEI follow up card you want to update and click the link</p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">2.</span>Update the form</p><p style="text-align: left; padding: 0px 0px 0px 15px; margin: 0px 0px 0px 10px;"><span style="font-size:10pt; font-family: 'Arial';color:#000000;display:inline-block;width:15px;margin-left:-15px">3.</span>Click Save</p></td>
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<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A5_ICON" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><span style="font-weight: bold;"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A5','TOGGLE0186A5_ICON')">Example of HEI Card - Part I</a></span></td></tr></table></div><div id="TOGGLE0186A5" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><p>&nbsp;</p>
<p><img src="keheifollowupcard.png" width="650" height="1712" alt="KEHEIFollowupCard" style="border:none" /></p>
</td>
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<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A6_ICON" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><span style="font-weight: bold;"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A6','TOGGLE0186A6_ICON')">Example of HEI Card - Part II</a></span></td></tr></table></div><div id="TOGGLE0186A6" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><p>&nbsp;</p>
<p><img src="keheifollowupcardpartii.png" width="650" height="497" alt="KEHEIFollowupCardPartII" style="border:none" /></p>
</td>
</tr>
</table>
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<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A7_ICON" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><span style="font-weight: bold;"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A7','TOGGLE0186A7_ICON')">Example of HEI Card - Part III</a></span></td></tr></table></div><div id="TOGGLE0186A7" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><p>This is a combination of the HEI and the maternal History</p>
</td>
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<p>&nbsp;</p>
<div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none;border-spacing:0px;padding:0px;line-height: normal;"><tr style="vertical-align:baseline"><td style="border:none;padding:0;width:18px"><img id="TOGGLE0186A8_ICON" src="hmtoggle_arrow1.gif" width="9" height="9" alt="hmtoggle_arrow1" style="border:none" /></td><td style="border:none;padding:0"><span style="font-weight: bold;"><a class="dropdown-toggle" href="javascript:HMToggle('toggle','TOGGLE0186A8','TOGGLE0186A8_ICON')">Data Dictionary</a></span></td></tr></table></div><div id="TOGGLE0186A8" style="text-align: left; text-indent: -18px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 28px;"><table class="toggletable" style="border:none; border-spacing:0px;">
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; padding:2px;"><div style="text-align: left; text-indent: 0px; padding: 0px 0px 0px 0px; margin: 0px 0px 0px 10px;"><table style="border:none; border-spacing:0px; border-collapse:collapse;">
<tr style="text-align:left;vertical-align:top;">
<td colspan="8" style="vertical-align:top; height:19px; background-color:#333399; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 11pt; font-weight: bold; color: #ffffff;">HEI Infant Follow up card</span></p>
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<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:31px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt; font-weight: bold;">Form/Registration</span></p>
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<td style="vertical-align:top; width:159px; height:31px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt; font-weight: bold;">FieldName (no spaces)</span></p>
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<td style="vertical-align:top; width:157px; height:31px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt; font-weight: bold;">Labelled (In the form)</span></p>
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<td style="vertical-align:top; width:164px; height:31px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt; font-weight: bold;">Options/list/units</span></p>
</td>
<td style="vertical-align:top; width:130px; height:31px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt; font-weight: bold;">Nature of the field</span></p>
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<td style="vertical-align:top; width:106px; height:31px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt; font-weight: bold;">Associated fields</span></p>
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<td style="vertical-align:top; width:53px; height:31px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt; font-weight: bold;">Required Field (Yes/No)</span></p>
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<td style="vertical-align:top; width:61px; height:31px; background-color:#ccffff; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt; font-weight: bold;">Data Quality Check (Yes/No)</span></p>
</td>
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<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Infant Profile</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
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<td style="vertical-align:top; width:157px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
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<td style="vertical-align:top; width:164px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
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<td style="vertical-align:top; width:130px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
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<td style="vertical-align:top; width:106px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
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<td style="vertical-align:top; width:53px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
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<td style="vertical-align:top; width:61px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
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<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEIIDNo</span></p>
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<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI ID Number</span></p>
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<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
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<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
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<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
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<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">ChildsName</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Name</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">GenderOfChild</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Sex</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Male, Female</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">DOB</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date Of Birth</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">BirthWeight</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Birth Wt ( Kg)</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Decimal Text Box</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">EnrollmentDate</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date Of Enrollment</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">EnrollmentAge</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Age at Enrollment</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Numeric</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:31px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:31px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">ChildRefferdFrom</span></p>
</td>
<td style="vertical-align:top; width:157px; height:31px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Source of Referral</span></p>
</td>
<td style="vertical-align:top; width:164px; height:31px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Paediatric, OPD, Maternity, CCC, MCH/PMTCT, Other Specify</span></p>
</td>
<td style="vertical-align:top; width:130px; height:31px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:31px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:31px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:31px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">OtherChildRefferalSource</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Other Specify</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">ChildRefferalSource</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:46px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:46px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">ChildPEPARVs</span></p>
</td>
<td style="vertical-align:top; width:157px; height:46px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">ARV Prophylaxis</span></p>
</td>
<td style="vertical-align:top; width:164px; height:46px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">SdNVP Only, SdNVP+AZT+3TC, NVP for 6 weeks (mother on HAART or not BF), NVP during BF, None</span></p>
</td>
<td style="vertical-align:top; width:130px; height:46px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:46px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:46px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:46px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">OtherPEP</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Specify other PEP Dispensed</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">NO</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">ContactTB</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">History of TB Contact in household</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes, No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Parent Profile</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">MothersName</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Name of mother</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">StateOfMother</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Alive?</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Alive, Dead</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">MotherRefferdToARV</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Mother Received Drugs for PMTCT?</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes, No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:31px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:31px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">PMTCTRegimen</span></p>
</td>
<td style="vertical-align:top; width:157px; height:31px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">If Yes Select Drug Combination</span></p>
</td>
<td style="vertical-align:top; width:164px; height:31px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">SdNVP,Interrupted HAART, AZT+NVP+3TC, HAART Specify.</span></p>
</td>
<td style="vertical-align:top; width:130px; height:31px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:31px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:31px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:31px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">OtherPMTCTRegimen</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Specify other PMTCT Regimen</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">OnART</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">On ART at Enrollment of Infant?</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Yes, No</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">MothersPointOfCare</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">CCC where PMTCT was dispensed</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">DeliveryMode</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Mode Of Delivery</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">SVD, C-Section</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">DeliveryLocation</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Place Of Delivery</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Facility, Home</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Immunisation History</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:46px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:46px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Immunisation</span></p>
</td>
<td style="vertical-align:top; width:157px; height:46px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Immunisation received by Child</span></p>
</td>
<td style="vertical-align:top; width:164px; height:46px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">BCG, OPV at Birth, OPV/Penta 1, OPV/Penta 2, OPV/Penta 3, Measles at 6 mnths, Measles at 9 mnths, Other Specify</span></p>
</td>
<td style="vertical-align:top; width:130px; height:46px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Multi Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:46px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:46px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:46px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">OtherImmunisation</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Specify other immunisation</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Immunisation</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Laboratory Information</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">FirstPCRDate</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date of First PCR</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">FirstPCRResults</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Results of First PCR</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Positive, Negative, Sample Rejected</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">FirstPCRSampleCode</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">First PCR DBS Sample Code</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">RepeatPCRDate</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Repeat PCR Date ( For rejections)</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">RepeatPCRResults</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Results of repeat PCR</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Positive, Negative, Sample Rejected</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">RepeatPCRSampleCode</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Repeat PCR DBS Sample Code</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">FirstAntiBodyTestDate</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date of First Antibody Test</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">FirstAntiBodyTestResult</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Result of First Antibody Test</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Positive, Negative, Indeterminate</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">ConfirmatoryPCRDate</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date of Confirmatory PCR</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">ConfirmatoryPCRResult</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Results of Confirmatory PCR</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Positive, Negative, Sample Rejected</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">ConfirmatoryPCRSampleCode</span></p>
</td>
<td colspan="2" style="vertical-align:top; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">DBS Sample Code for Confirmatory PCR</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">RepeatConfirmatoryPCRDate</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date Confirmatory PCR Date</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">RepeatConfirmatoryPCRResult</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Results for Repeat Confirmatory PCR</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Positive, Negative, Sample Rejected</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">RepeatConfirmatoryPCRSampleCode</span></p>
</td>
<td colspan="2" style="vertical-align:top; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">DBS Sample Code for Repeat Confirmatory PCR</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">FinalAntibodyTestDate</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date of Final Antibody Test</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Date</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">FinalAntibodyResults</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Results of Final Antibody Test</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Positive, Negative, Indeterminate</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Patient Locator Address One</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Address1</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Address 1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Current, Permanent</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">RelationshipAddress1</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Relationship Address 1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Parent, Guardian, Other Specify</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">OtherrelationshipAddress1</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Specify Other relationship Address 1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">ContactName1</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Name contact 1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">PhoneContact1</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Phone Contact 1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Numeric</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">DistrictContact1</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">District Contact 1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">EstateVillage1</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Estate / Village Contact 1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HouseNumberContact1</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">House Number Contact 1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">ChiefContact1</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Sub / Chiefs Name Contact 1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">LandmarkContact1</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Landmark Contact 1</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Patient Locator Address Two</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; background-color:#969696; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Address2</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Address 2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Current, Permanent</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">RelationshipAddress2</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Relationship Address 2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Parent, Guardian, Other Specify</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Select list</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">OtherrelationshipAddress2</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Specify Other relationship Address 2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">ContactName2</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Name contact 2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">PhoneContact2</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Phone Contact 2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Numeric</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">DistrictContact2</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">District Contact 2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">EstateVillage2</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Estate / Village Contact 2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HouseNumberContact2</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">House Number Contact 2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">ChiefContact2</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Sub / Chiefs Name Contact 2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
<tr style="text-align:left;vertical-align:top;">
<td style="vertical-align:top; width:154px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">HEI Infant Follow up card</span></p>
</td>
<td style="vertical-align:top; width:159px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">LandmarkContact2</span></p>
</td>
<td style="vertical-align:top; width:157px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Landmark Contact 2</span></p>
</td>
<td style="vertical-align:top; width:164px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:130px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">Text Single line</span></p>
</td>
<td style="vertical-align:top; width:106px; height:15px; padding:0px; border:solid 1px #000000;"><p style="text-align: right; margin: 0px 0px 0px 0px;"><span style="color: #000000;">&nbsp;</span></p>
</td>
<td style="vertical-align:top; width:53px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
<td style="vertical-align:top; width:61px; height:15px; padding:0px; border:solid 1px #000000;"><p style="margin: 0px 0px 0px 0px;"><span style="font-size: 9pt;">No</span></p>
</td>
</tr>
</table>
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